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Measles in the United Kingdom - The “Wakefield Factor”

Dr. Andrew Wakefield
has been persecuted and vilified ever since he published an article in
Lancet in
February 1998 and answered questions about MMR vaccination at a press
conference in London.

Of all the insults
and accusations leveled against Dr. Wakefield, the most painful must
have been
that because of his research, children in the United Kingdom and
elsewhere were
more likely to come down with measles and die.

Dr Wakefield’s
recommendation for single measles vaccine in preference to MMR was made
after
his extensive review of the quality of safety data in relation to
measles-containing vaccines and the revelation, by a senior member of
the UK
Department of Health, about the licensing of knowingly unsafe MMR
vaccines by
the UK
authorities.[1]
His position on the
relative paucity of good safety data for MMR compared with the single
measles
vaccine has since been endorsed by the Cochrane Collaboration.[2]
It is important to note that at the time of The
Lancet publication and beyond, Dr Wakefield strongly endorsed the
use of
single measles vaccine. Despite false allegations to the contrary by The Lancet editor, Dr Richard Horton[3],
single vaccines were available in the UK when Dr Wakefield made this
recommendation.

In order to protect
the MMR vaccine programs the option of single vaccines was later
removed from
parents wishing to vaccinate their children, but concerned, quite
reasonably,
over the safety of MMR.

In the UK,
the government withdrew the importation license for single vaccines a
few
months after Dr Wakefield’s 1998 press conference. Well worth noting is
the
fact that Merck ceased supplying the single measles, mumps and rubella
vaccines
in the United States over ten years later, in October 2009[4].

Because of
inconsistent testing results and non-availability of pre-1998 data, it
is near
impossible to define a trend or to draw conclusions regarding confirmed
measles
cases; yet the relatively few confirmed cases of measles in the UK
received an inordinate amount of publicity that always included
extensive blame
of Dr. Wakefield, particularly as his GMC hearing approached.

While this was
happening in England,
multiple measles outbreaks were being reported worldwide, sometimes in
highly
vaccinated populations.

Official statistics
from the United Kingdom Health Protection Agency show that:

The number of reported
measles cases kept dropping after1998 and only
exceeded the 1998 figures ten years later, when there were outbreaks
worldwide

There were strikingly
far fewer reported measles cases in the UK in the 10 years that
followed Wakefield’s paper than in the 10 years that preceded its
publication

The reporting of
measles cases in the United Kingdom was not affected by Dr. Andrew
Wakefield’s research.

Measles in the United
Kingdom

The role of the Health Protection
Agency (HPA)[5]
is “to provide an
integrated approach to protecting UK public health through the
provision of support and advice to the NHS … The Centre for Infections
at
Colindale is the base for communicable disease surveillance and
specialist
microbiology …”

According to the HPA, “After clean
water, vaccination is the most effective public health intervention in
the
world for saving lives and promoting good health.”[6]

The HPA lists in a single master
table[7],
the
annual totals from 1982 to 2009 for England
and Wales,
of all “Statutory Notifications of Infectious Diseases (NOIDs)”.

Selected measles information for the
years 1988-2007 from that particular HPA Master Table is listed in the
following table.

Table I - HPA: Measles Reported Cases –
England and Wales

Totals

10 YearsPre-Wakefield

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

Last 5

All

86,001

26,222

13,302

9,680

10,268

9,612

16,375

7,447

5,614

3,962

43,010

188,483

10 YearsPost-Wakefield

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

First5

All

3,728

2,438

2,378

2,250

3,187

2,488

2,356

2,089

3,705

3,670

13,981

28,289

The MMR vaccine was licensed and the
MMR vaccination program was launched in the United Kingdom in 1988.

There were 188,483 reported measles
cases in the ten years preceding the Wakefield
paper compared to 28,289 cases in the following ten years, an 85%
decrease.

Although increasing uptake of the
MMR vaccine could account for much of the early decline, the fact that
there
were 43,010 reported measles cases in the five years preceding the
publication
compared to 13,981 cases in the following 5 years, a decrease of 67%,
suggests
that there was no “Wakefield Factor”, at least insofar as an impact on
reported
measles cases is concerned.

If one postulated that the UK MMR
vaccination rates near-reached targeted levels 3 years after the launch
of the
vaccination program and compared the 7-year periods before and after
the
Wakefield paper, the following would also be obvious: There were only
18,825
measles notifications in the 7 years following the publication of the
paper in
early 1998 compared to 62,950 measles notifications in the previous 7
years.

The fact that the number of notified
measles cases decreased from 1998 to 1999 to 2000 to 2001, the 4 years
immediately after the Wakefield
publication and press conference, when maximal impact should have been
noted
clearly speaks for itself.

The same holds true when calculated as cases per 100,000 of population.

Dr. Elizabeth Miller, Head of
the Immunization Department at the Health Protection Agency, Center for
infections, and a member of the WHO Global Advisory Committee on
Vaccine
Safety, was never a fan of Dr. Wakefield.
A staunch defender of the MMR vaccination program and the author /
co-author of
eight publications on MMR vaccination and autism between 2002 and 2005,
she
never once revealed in her many addresses that reported measles cases
had
decreased after The Lancet paper.

Neither did Sir Liam Donaldson, the Chief Medical Officer nor Professor
David Salisbury, Director of Immunization at the UK Department of
Health.

The World Health Organization (WHO) lists infectious diseases reported by all nations.

The following table
lists that data[8]
for the ten years before
and after the Wakefield
paper as reported by the UK Health Authorities, possibly the HPA.

Table II - WHO: Measles Reported Cases – UK
and Northern Ireland

Totals

10 YearsPre-Wakefield

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

Last 5

All

88,259

30,160

28,228

11,727

12,317

12,018

23,525

9,017

6,866

4,844

56,270

226,961

10 YearsPost-Wakefield

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

First5

All

74

-

104

73

314

460

189

79

764

1022

565

3,079

An attempt at explaining the above
somewhat inconsistent numbers will follow. The fact remains that the
reported
cases of measles in the United Kingdom
and Northern Ireland
did not increase and actually decreased in the years immediately
following the
1998 publication by Wakefield et al in The
Lancet.

This is further supported by Jick
and Hagberg of the Boston University School of Medicine Collaborative
Drug
Surveillance Program[9]
who identified all children
in the UK General Practice Research Database diagnosed
with measles from 1990 to 2008and
recently reported (June 2010) that
“…Since 1996, the incidence of measles has fallen …”

Reported cases of measles[10]decreased 15 to 44% in England and Wales between 1998
and 2007. They also
decreased from year to year during 5
of the 6 years that followed the Wakefield
paper in spite of the frenzied publicity.

Trying to make sense of the number
and percentage of confirmed measles cases
in the UK
since 1998 is a challenge. As evident in the following table, the
number and
percentage of confirmed cases spiked in 2002 and again in 2006-2007.

A comparison of the data for the
2002 and 2007 spikes illustrates the difficulty to draw conclusions.
While
reported cases rose from 3,187 to 3,670, an increase of 15%, confirmed
cases
jumped disproportionately from 319 to 990, an increase of 210%.

Looking at the 2002 spike and
comparing 2001 with 2002, reported cases increased by 42% from 2,250 to
3,187
while confirmed cases increased by 355% from 70 to 319.

Comparing the first quarters of both
years was also helpful.

There were 741 notified measles
cases and 569 (72%) tested. Only 3 had a positive saliva test, a yield
of 0.5%
from weeks 1 to 13 of 2001.[11]

During the same weeks of
2002,[12]
there were 1,199 notified cases and 1,386 (116%) tested cases. The
following
explanation was provided by the Public Health Laboratory Services
(PHLS) for
this strange situation: “due to the
increase in confirmedmeasles in
this quarter many oral fluid tests were submitted early for detection
of IgM
antibody forsuspected cases, some
of which
were not subsequently notified, thus more samples were submitted than
notified
in this period.”

[No
lucid comment on the above statement is possible.]

In
any case, of the 1,386 tested cases, 91 or 6.6% were positive, a yield
13 times
greater than in the first quarter of 2001. Because 9 cases had recently
been
vaccinated, PHLS recorded the confirmed saliva-tested cases as 82.
Unlike in Q1
of 2001, PHLS then added 44 “other
lab confirmed cases” to push the number of confirmed cases to 126 for
the
quarter.

In
spite of all the changes and lack in conformity, there were fewer confirmed cases of measles[13]
in England and Wales
in 2005 than in 1999. Also noteworthy
is the fact that the percentages of confirmed cases remained low during
the four
years that immediately followed the publication of the Wakefield study.

The fact that there were only 2,089
notified cases and 78 confirmed measles cases in 2005, while
the same diagnostic modalities as in 2002-2004 were in use,
strongly suggests that seven years after the Lancet publication, the
so-called
Wakefield Factor was still not much of a factor.

A careful look at the first quarter
of 2005[14]
may help shed some light on the issue of case confirmation in the
United Kingdom
by saliva testing. In week 1 to 13, 2005 there were 591 reported cases
of
measles of which 575 (97.3%) were tested. In only 20 (3.5%) the saliva
test was
positive.

The same was true for rubella: Of
299 cases of clinical rubella reported by physicians during the
quarter, 220
had a saliva test performed and only 2 (0.9%) of the 220 tests were
positive.

The results for mumps testing were
much different. During the same quarter, 5,945 cases of mumps were
reported,
3,356 or 56.5% were tested and 1,381 (41%) were positive by the saliva
test.

Clearly, the validity of measles,
rubella and even mumps reporting is suspect.

A similar picture was also evident
in the second and third quarters of 2005.[15][16]

Oral fluid testing (saliva) for
measles, mumps and rubella began in the UK in 1995.[17]
It is worth noting that until 1998, the health authorities continued to
provide
counts of reported and not of confirmed measles cases to the World
Health
Organization. (See WHO table above).

It is important to point out that
the increases in reported and confirmed cases of measles during 2006
and 2007
were part of the global increase in measles activity still going on and
will be
discussed in the next section.

Considering measles-related deaths in
the UK
and according to information provided by HPA[18]
and
updated April 13, 2010: “In 2006 there was one
measles death in a 13 years old male who had an underlying lung
condition and
was taking immunosuppressive drugs. Another death in 2008
was also
due to acute measles in unvaccinatedchild with congenital
immunodeficiency whose condition did not require
treatment with immunoglobulin. Prior to 2006, the last death
from
acute measles was in 1992. All other measles deaths, since
1992, shown above are in older individuals and were caused by the
late
effects of measles. These infections were acquired during the 1980s or
earlier,
when epidemics of measles occurred.”

Measles outbreaks worldwide

Measles outbreaks have been
occurring worldwide since 2006 even in highly vaccinated countries.

In Saudi Arabia[19],
where
infants routinely receive a monovalent measles vaccine at age 9 months
and two MMR vaccines, at age 1 and again at age 4-6 years and where
vaccination
rates with measles-containing vaccines have consistently been between
95 and
98% during the last 6 years, there were 4,648 cases of measles in 2007
compared
to 373 cases in 2005, 807 in 2006, 157 in 2008 and 82 in 2009.

So in 2007, in spite of the superior
vaccination rates in Saudi Arabia, there were 4,648 reported cases of
measles in an estimated population of 27.6 million. In the same year,
there
were 3,670 reported cases of measles, of which 990 were confirmed, in
the United Kingdom,
estimated population 61 million.[20]

In Switzerland, the MMR vaccine has been licensed and used since 1985
when a catch-up vaccination was also recommended for teenagers aged 12
- 15 years. A second dose of MMR was recommended in 1996. Vaccination
coverage for at least one dose by age 2 remained stable at around 82%
during the decade of the nineties. It increased to around 87% in 2005 -
2007. For eight-year olds, the MMR vaccination rate was 90% while for
adolescents, it was at 94%. Full vaccination with two doses of MMR
reached 71 to 76% in Switzerland.

There were on average 50 notified cases
of measles
a year in Switzerland
(population 7.5 million) from 1999 to 2006 except for 2003, when there
was an
outbreak of 612 cases.

From November 2006 to September 2009,
Switzerland
experienced a full scale epidemic with 4415 reported measles cases. The
incidence rates of 15 per
100,000 in 2007 and 29 per 100,000 in 2008 were reportedly the
highest in Europe.[21]

Switzerland and Saudi Arabia
use serum and not saliva
testing to confirm measles cases.

Measles outbreaks are still going on
worldwide regardless of vaccination rates as evidenced by a CDC Update
to
Travelers dated September 9, 2010[22]
stating: “Measles remains a common disease in many parts of
the world. An estimated 10 million cases and 164,000 deaths from
measles occur
worldwide each year… Measles outbreaks are common in many areas
including Europe …”

In England, any report of a small
cluster of measles was an opportunity to blame Dr. Wakefield and his
research,
particularly as the much advertised GMC hearings got underway. [23][24][25]

Even a single confirmed case of
measles in an unvaccinated or under-vaccinated English child always
signaled an
avalanche of blame by many who should have remembered that it was not
Andrew
Wakefield who banned the importation of the single vaccines in 1999

Meanwhile,
Autism Spectrum Disorders have increased
in Great Britain
at an alarming rate. As described in an article on March 2, 2006, there were 3,484 schoolchildren with
autism in Scotland
in 2005, compared to only 820 in 1998, a four-fold increase.[26]

More
recently,
(June 2009), Professor Baron-Cohen et
al[27]
estimated the prevalence of
autism-spectrum conditions in the UK to be 157 per 10 000.

Conclusions

For the last 12 years,
Andrew
Wakefield has been abused and attacked for having dared say that
research was
needed to rule out an MMR vaccine-autism connection in a small subset
of
genetically predisposed children. His suggestion to have single
vaccines
available until such research was done was also harshly and
consistently
criticized.

Wakefield accusers have never mentioned the fact that the UK Department of Health stopped the
importation
of the monovalent measles, mumps and rubella vaccines in order to force
parents
to accept the MMR, giving those who were concerned about its safety and
unwilling
to go the triple-vaccine route, difficult
choices: To buy the single vaccines at private clinics in England, to
take a
train ride to France to get them a little cheaper or … to do nothing.

The most painful insult hurled against Dr. Wakefield must have been the
allegation that his research caused measles epidemics and killed
children.

The unrelenting press
coverage,
the explosion in the number of autism cases in the UK and the reports
by some parents
that their children regressed after MMR vaccination were in all
likelihood more
responsible for the drop in MMR vaccination rates than an article in The Lancet and a statement at a press
conference in 1998.

Another important but
rarely
mentioned factor, was that young parents who saw how shabbily families
who had
children with MMR-related regression and GI disorders were treated by
the
authorities, how their legal aid was curtailed and how thousands went uncompensated, decided to forgo the
vaccination altogether rather than take a chance.

However, whatever the reasons for the drop in
vaccination
rates in England, it appears that when measles outbreaks occurred in
the United
Kingdom in the last twelve years they also occurred in Europe and
elsewhere in
the world, often in well vaccinated populations.

The evidence presented
here is
clear: According to official UK Government reports, the number
of
notified measles cases decreased from 1998 to 1999 to 2000 to 2001 and
there
were fewer cases of the disease during the ten years that followed the
Wakefield paper than in
the previous ten years.

It is impossible to draw reasonable conclusions
concerning
the number of confirmed measles cases in the United Kingdom during the
last
twelve years. What seems clear is that increases coincided with
worldwide
measles activities or sudden changes in diagnostic techniques and
classification.

According to HPA statistics, there was no
“Wakefield
Factor”.

It is time to stop blaming Andrew Wakefield and
start
putting the blame where it belongs.